Let’s Talk About the Types of Psoriasis
There are multiple forms of this scaly skin condition, and which one you have will determine the treatment you receive.by Krista Bennett DeMaio Health Writer
With 125 million people in the world who have psoriasis, chances are you know someone who has the condition. But what you may not know is that there are several types of the chronic skin disease. They tend to get lumped in with the most common one: plaque psoriasis, which accounts for a whopping 80% of all cases. But there are six others that look, act, and may even be treated differently than the rest. Knowing which one you have can help you get better, faster.
Our Pro Panel
For the most up-to-date info on the types of psoriasis, we reached out to top skin doctors across the country.
April W. Armstrong, M.D.
Professor of Dermatology, Associate Dean for Clinical Research and Psoriasis Program Director
Keck School of Medicine and Department of Dermatology at the University of Southern California (USC)
Los Angeles, CA
Lawrence Eichenfield, M.D.
Chief of Pediatric and Adolescent Dermatology, Professor of Dermatology and Pediatrics
Rady Children's Hospital and University of California, San Diego School of Medicine
San Diego, CA
Gretchen W. Frieling, M.D.
Both can be itchy and cause shedding onto your hair, clothes and furniture. But the similarities stop there. Scalp psoriasis, like plaque psoriasis, is an autoimmune disease that is usually chronic and incurable. On the other hand, dandruff can go away on its own or be treated with a mild dandruff shampoo (if it’s caused by dry weather, for instance) and doesn’t require medical attention.
Yes. In fact, keeping nails clean and trimmed and not biting them can help, and the cosmetic benefit can make you feel better about your nails. Be sure to tell your manicurist you have psoriasis because it’s easily mistaken with a fungal infection, which is contagious. One tip: Avoid long soaks. It robs your nails of moisture and that can make your nail psoriasis worse.
Around 85% of people develop skin psoriasis first or at the same time as psoriatic arthritis. Only about 15% get arthritis symptoms before the skin disease. Psoriasis is most likely to develop between 15 and 35 years old, while psoriatic arthritis shows up between ages 30 and 50.
For some people, guttate psoriasis, characterized by spotty, scaly lesions on arms, legs and torso, may come once and never return. It is commonly triggered by infections, like a common cold or strep throat. Once you treat it, it may be gone for good.
What Is Psoriasis, Again?
Red, scaly, painful patches or bumps on your skin are the telltale signs of this inflammatory skin condition. It happens when your skin cells turn over at a way-too-fast rate (10 times faster than normal), causing a pile up of cells on the skin’s surface that form those angry, red patches, or plaques. Why this happens isn’t so clear, but researchers believe psoriasis is caused by a mix of genetics, an overactive immune system, and triggers such as bacterial infection, skin trauma, smoking, medications, and obesity, just to name a few.
As we mentioned above, there are seven different types of psoriasis:
There’s also psoriatic arthritis, a combo of psoriasis and arthritis. Here’s what you need to know about the causes and treatments for each one.
What You Should Know About Plaque Psoriasis
This is the type you’re probably thinking of when someone mentions psoriasis. It’s characterized by clearly demarcated, raised, red, scaly patches called plaques that appear most commonly on your elbows, knees, scalp, and back (but they can pop up anywhere on the body).
Because it accounts for 80% of all cases, plaque psoriasis tends to get the most press. It’s the type addressed in most psoriasis drug commercials, and celebs including reality star Kim Kardashian and singer Cyndi Lauper have both been vocal about being plagued with plaques.
What Causes Plaque Psoriasis?
The cause for all cases of psoriasis stems from a combo of genetics, immune dysfunction, and triggers. People who have psoriasis are also more likely to have other inflammatory diseases such as Crohn’s disease, heart disease, or diabetes, suggesting some link between the underlying inflammation.
A study in Archives of Dermatology that looked at over 100,000 patients with psoriasis found those with severe psoriasis had a 46% greater chance of having diabetes than those without the skin disease.
How Do You Treat Plaque Psoriasis?
There are several treatments that target plaques. Your physician will decide which one is right for you based on your general health, any underlying conditions, and the severity of your plaque psoriasis. Your options include:
Topical ointments and creams such as cortisone cream, oral or injectable corticosteroids
Light therapy (phototherapy)
Systemic drugs such as Gengraf and Sandimmune (cyclosporine) and Rasuvo and Rheumatrex (methotrexate)
Biologic medications, which are made from living organisms and work by slowing down your overactive immune system
Research suggests that biologics for psoriasis might help with those other inflammatory diseases linked to the skin condition, too. A study in Cardiovascular Research found that treating psoriasis with biologics helps reduce the plaque buildup in the arteries, which leads to heart attacks and strokes.
However, once your skin plaques disappear, you’re not necessarily in the clear. Exposure to your triggers can bring on a new bout of plaque psoriasis. Only 10% of people are lucky enough to have what’s called “spontaneous remission,” when your skin clears up forever and you never have a flare up again.
What You Should Know About Scalp Psoriasis
If you’re scratching your head over an itchy scalp condition that won’t clear up with a traditional dandruff shampoo, you may have scalp psoriasis. This type can go hand-in-hand with plaque psoriasis (see above), or even appear in those who don’t have any history of the skin disorder at all.
It’s often confused with dandruff, because, well, it itches and causes flakes, only these flakes are typically silvery-white and scaly. You might also have painful red scales or silver plaques on your head. In severe cases, scalp psoriasis appears as thickened, crusty patches of skin not only on the hairline, but also on the forehead, back of the neck and near the ears.
What Causes Scalp Psoriasis?
Unlike dandruff, scalp psoriasis doesn’t come and go with the weather, hormonal fluctuations, or changes in hair products. The cause is the same as other types of psoriasis: an overactive immune system, genetics, and triggers such as stress and certain medications. But in this case, the plaques that show up may only show up on your scalp.
How Do You Treat Scalp Psoriasis?
Mild cases can be nipped in the bud or improved with salicylic-, coal-tar-, or clobestasol propionate-containing (a topical steroid) shampoos. More severe cases may require systemic or biologic drugs, oral treatments, light therapy, or a combination of treatments. Unfortunately, you may lose some hair with some of these treatments, which is usually temporary.
What You Should Know About Nail Psoriasis
If you’ve “nailed it” with psoriasis, then you know all too well that this type brings pitted, discolored, thickened, and even deformed fingernails and/or toenails. In severe cases, the nail plate can lift from the nail bed and you may see some gunk or even blood in between.
What Causes Nail Psoriasis?
Of all the people who have some type of psoriasis, up to 50% will also have nail psoriasis. Like scalp psoriasis, it often comes along with plaque psoriasis, but it can also accompany other types or appear all on its own, too. Those with psoriatic arthritis will have an 80% chance of having nail psoriasis, too.
The same underlying causes as plaque psoriasis are at play here, too, revving up your skin cell production. Nails are considered part of the skin (they’re literally made up of skin cells), which is why they are also affected by the disease.
How Do You Treat Nail Psoriasis?
Typically, mild cases are treated with topical ointments rubbed into the nails such as:
a vitamin D derivative
a topical retinoid such as tazarotene
More severe cases might require:
an immune suppressing oral medication
a biologic injection or intravenous infusion
What You Should Know About Guttate Psoriasis
This type doesn’t bring large plaques, but instead little red bumps smaller than a fingertip. You can wind up with hundreds of them scattered on your arms, legs, and torso.
About 10% of all psoriasis cases are the guttate type. You can have a mild case with just a few spots in one area, a moderate case that covers up to 10% of your body, or a severe breakout that leaves most, or even all, of your body covered in bumps.
What Causes Guttate Psoriasis?
This type often stems from a bacterial infection such as strep throat, an upper respiratory infection, or tonsillitis. There is also a genetic component. If a family member has had guttate psoriasis, you’re more likely to get it, too.
How Do You Treat Guttate Psoriasis?
Because guttate psoriasis is commonly triggered by infections, once you treat the infection, the psoriasis usually goes away, too. If the skin condition lingers, or you have a severe case, your physician may want to treat your symptoms with topical steroids and/or phototherapy, artificial UVB light that halts the inflammatory process.
What You Should Know About Inverse Psoriasis
This type affects fewer than 10% of people with psoriasis. It’s called “inverse” psoriasis because it appears in unusual places such as the groin, armpits, bellybutton, genitals, under the breasts and behind the knees. Often, it’s accompanied by one of the other types of psoriasis listed here.
What Causes Inverse Psoriasis?
The same underlying culprits can lead to this type, only it’s brought on by sweat and friction. That’s why it’s commonly found in areas where there is skin-to-skin rubbing and moisture. Weight seems to be a factor, too. If you’re overweight, you’re more likely to have skin folds, prime spots for inverse psoriasis.
How Do You Treat Inverse Psoriasis?
The gold standard is typically topical steroids and ointments in those vulnerable spots where moisture and friction are likely. If those don’t work, phototherapy, and systemic treatments are an option.
What You Should Know About Pustular Psoriasis
As the name implies, this type causes pus-filled bumps. These white spots can appear anywhere on your body, but most commonly the hands and feet. The bumps come on suddenly and look infected, but they’re not.
The real danger here is damage to the skin’s barrier, the outermost protective layer of your skin. That means your skin can’t retain water or nutrients, while also allowing bacteria and other irritants to get a fast pass into your body. As a result, in some cases, pustular psoriasis can be deadly, so make an appointment with your doctor asap, if you develop it.
There are a few sub-types of pustular psoriasis:
Von Zumbusch: This form features pustules that appear and then dry up, leaving skin with a glazed look.
Palmoplantar pustules: This version shows up on the palms of your hands and the soles of your feet.
Acropustulosis: This type is characterized by pustules that burst and ooze. In severe cases, this type can cause bone or nail deformity.
What Causes Pustular Psoriasis?
At the risk of sounding like a broken record, genes are to blame. But researchers have dug deeper and discovered a specific gene mutation that may be responsible for pustular psoriasis.
A study in the American Journal of Human Genetics ID’d the gene AP1S3. If you have this particular genetic predisposition, the triggers for pustular psoriasis are often infection, stress, hormonal changes such as pregnancy, and exposure to chemicals. Also, certain drugs such as OTC pain relievers and anti-inflammatory drugs, penicillin, and some antidepressants such as lithium can trigger a flare. Stopping a course of steroids too fast can bring on a flare of pustular psoriasis, too.
How Do You Treat Pustular Psoriasis?
Your doctor may prescribe a topical retinol or an immune-suppressing biologic such as Remicade (infliximab) to calm inflammation and stop the bumps. In severe cases, you may get a combo of a biologic and an oral immune-calming med such as Trexall (methotrexate) to get it under control.
What You Should Know About Erythrodermic Psoriasis
The rarest of all psoriasis types, erythrodermic psoriasis affects only 2% of those with psoriasis. This type causes redness from head to toe, as if your skin has been burned. Even worse, it’s possible that your skin could peel off in sheets.
As with the pustular type, erythrodermic psoriasis severely compromises the skin’s protective barrier, so swift medical attention is a must. You can also develop fever, chills, swollen, painful joints, and rapid heart rate.
What Causes Erythrodermic Psoriasis?
This type can be triggered by a bad sunburn, an infection, drug reaction, stopping a medication too abruptly, steroid use, stress, and alcoholism.
How Do You Treat Erythrodermic Psoriasis?
Your doctor will likely start with an immune suppressant. To soothe your sore skin, you may be prescribed topical steroids, itch-suppressing medications, or prescription pain treatments.
What You Should Know About Psoriatic Arthritis?
An estimated 30% of people with psoriasis also have or will develop psoriatic arthritis, or PsA, a chronic autoimmune condition that affects 2-3% of the population. While psoriasis affects the skin, psoriatic arthritis affects the joints and some parts of the body where ligaments and tendons are attached to the bone, particularly in the fingers, toes, wrists, knees and spine. The result is stiffness, swelling, pain and, if not caught early, irreversible damage, which is why early diagnosis and treatment are important.
What Causes Psoriatic Arthritis?
PsA is an autoimmune disease. That means your immune system gets its messages mixed up and attacks healthy tissue, in this case, of your skin and joints. You’re also more likely to develop PsA if you have a family history of it (40% of people who have it also have a family member who has it, too), you already have psoriasis, and you’re between the ages of 30 and 50.
How Do You Treat PsA?
If you have this condition, you’ll want to see a rheumatologist, a doctor who specializes in arthritis. Treatments can range OTC non-steroidal anti-inflammatory drugs (NSAIDs) such as Advil (ibuprofen) to disease-modifying antirheumatic drugs (DMARDs), including methotrexate, that work by slowing your immune system and your body’s inflammatory response. If those don’t work, biologics may be considered.
Five Types of Psoriasis: National Psoriasis Foundation. (n.d.). “About Psoriasis.” psoriasis.org/about-psoriasis
Biologic Drugs, Psoriasis, and Cardiovascular Disease: Cardiovascular Research. (2019). “Coronary artery plaque characteristics and treatment with biologic therapy in severe psoriasis: results from a prospective observational study.” academic.oup.com/cardiovascres/article/115/4/721/5306384
Psoriasis and Diabetes: Archives of Dermatology. (2012). “Increased Risk of Diabetes and Likelihood of Receiving Diabetes Treatment in Patients with Psoriasis.” ncbi.nlm.nih.gov/pmc/articles/PMC3677207/
Treating Scalp Psoriasis: National Psoriasis Foundation. “Scalp Psoriasis.” (2020). psoriasis.org/about-psoriasis/specific-locations/scalp
Nail Psoriasis: Mayo Clinic. (n.d.). “Nail Psoriasis: Can treatment or home care help?” mayoclinic.org/diseases-conditions/psoriasis/expert-answers/nail-psoriasis-treatment/faq-20230374
Nail Psoriasis: National Psoriasis Foundation. (2020). “Managing Nail Psoriasis.” psoriasis.org/about-psoriasis/specific-locations/hands-feet-nails/managing-nail-psoriasis
Treatments for Nail Psoriasis: American Academy of Dermatology. (n.d.). “What is nail psoriasis and how can I treat it?” aad.org/diseases/psoriasis/nail-psoriasis
Genetics and Pustular Psoriasis: American Journal of Human Genetics. (2014). “AP1S3 Mutations Are Associated with Pustular Psoriasis and Impaired Toll-like Receptor 3 Trafficking.” ncbi.nlm.nih.gov/pmc/articles/PMC4067562/